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close this bookInnovative Approaches to HIV Prevention (UNAIDS, 2000, 55 p.)
View the document(introduction...)
View the documentACKNOWLEDGEMENTS
View the documentINTRODUCTION
View the documentMETHODOLOGY
View the documentWHAT WORKS IN HIV PREVENTION?
View the documentWHAT WORKS WITH YOUNG PEOPLE?
View the documentWHAT WORKS WITH WOMEN AND MEN?
View the documentWHAT WORKS WITH PEOPLE WHO INJECT DRUGS?
View the documentWHAT WORKS WITH MEN WHO HAVE SEX WITH MEN?
View the documentWHAT WORKS WITH SEX WORKERS AND THEIR CLIENTS?
View the documentANNEX. SUMMARY OF CASE STUDY RESULTS
View the documentREFERENCES
View the documentBACK COVER

WHAT WORKS WITH MEN WHO HAVE SEX WITH MEN?

In many developed countries, gay and other men who have sex with men were among the first to be affected by HIV, and continue to bear the brunt of the epidemic. In developing countries the situation is quite different. In many such countries heterosexual transmission accounts for the vast majority of reported cases. However, it is not clear whether or not this is an accurate reflection of the real situation. In many developing countries, male-to-male sex is highly stigmatized, and in some it is legally prohibited. This can cause governments, political leaders and the public at large to believe that homosexual transmission does not exist, when in fact it is simply hidden (National Research Council, 1996).

As time has passed, a new willingness to ‘lift the veil’ on hitherto stigmatized and denied behaviours has come about. In sub-Saharan Africa, for example, where virtually no cases of homosexual transmission were initially reported, there is now a growing body of literature to suggest that same-sex contacts are far more common than previously thought (see Aggleton, Khan & Parker, 1999 for a review). It is now clear that across a variety of countries in both the developed and developing world men who have sex with men (MSM) are made more vulnerable to HIV infection because of the clandestine nature of their relationships, and the marginalization and discrimination they face (McKenna, 1996; Aggleton, Khan & Parker, 1999). The challenge now is to expand on the limited number of innovative programmes for men who have sex with men, and to address the structural factors that promote this discrimination and stigmatization.

MSM CASE STUDY 1

Setting:

Community

Country:

Chile

Intervention:

IEC campaign and training of health professionals

Sponsoring institution/organization:

The Lambda Centre (a CBO)

A project initiated in 1995 by the Lambda Centre, a gay association in Santiago, Chile in collaboration with other nongovernmental organizations (NGOs) and some universities aimed to address the high incidence of HIV infection amongst homosexually active men who then accounted for 82% of all sexually transmitted HIV infections. Homosexual behaviour remains a criminal offence in Chile and the political climate up until democratization in 1990 has made work with gay men difficult in Chile. Nonetheless, a series of workshops with gay-identified men were held to promote open discussion and encourage the development of social networks, alongside the training of health and other professionals on sexuality and discrimination issues. Posters were produced and distributed, along with condoms and information on services. Work was carried out in relation to the defence of human rights and wider legal issues affecting gay men. A strategy to develop a network of supportive individuals and institutions, including those within the public health system, was also developed.

Over a five-year period, workshop content has been adapted and modified and tested out within different cultures and age groups in a variety of geographical locations. Efforts have been made to raise the profile of gay communities through their participation in public activities such as World AIDS Day events, Gay Pride marches and candlelight memorials. A strategy to raise awareness within the public health system was employed to make care and support programmes more appropriate and accessible to MSM. This included the training of health workers on issues of sexuality and homosexuality. Other activities included the distribution of condoms, information leaflets and advice on where good-quality HIV counselling and testing services were available. In addition, work has been carried out in relation to the defence of human rights and wider legal issues affecting gay men.

Process evaluations were conducted at each of the workshop sessions using an open-ended questionnaire format. The outcomes of this evaluation identified a felt need among gay men for social forums where they can communicate openly on issues affecting them, and derive support for the difficulties they face. Evaluation data were also collected to assess the extent and scope of the work. Between 1995 and 1997, 172 activities were implemented involving 1576 people in seven Chilean cities. Groundwork has been laid for the development of a more systematic approach to HIV prevention for men who have sex with men, which can be consolidated upon and expanded in the future. The project has been particularly innovative given the prevailing political climate, with gay organizations taking the lead in lobbying for changes in health care services, legal, civil and human rights and attitudes towards homosexuality.

MSM CASE STUDY 2

Setting:

Community

Country:

Jamaica

Intervention:

Counselling, education and outreach activities

Sponsoring institution/organization:

Jamaica AIDS Support (an NGO)

A project was designed and implemented by Jamaica AIDS Support (JAS), a nongovernmental volunteer-based support and education group for men who have sex with men (MSM). Widespread discrimination against MSM has made it difficult to implement HIV prevention work in Jamaica, and as men with HIV became unwell, very limited support has been available for them and their families. The specific purpose of the outreach and risk reduction project was to increase JAS’s capacity to support risk reduction among MSM in three discrete geographical areas. Comprising 80 volunteers, JAS met weekly and held educational outreach events and provided support to people living with HIV/AIDS. Peer counselling was carried out to promote self-esteem, a positive attitude towards sexual health, and lasting behavioural change. Peer counsellors provided education to men who have sex with men and to their families, including 24-hour support for families of people living with AIDS. Regular support group meetings have explored topics such as safer sex, gay relationships, prostitution, education, homophobia and strengthening the gay community. Long-term counselling and support services for people living with HIV/AIDS have included telephone counselling and, importantly, the provision of home-based and hospice care at the ‘Life’ hospice established by JAS with financial support from their funders AIDSCAP. Monthly special events included parties, which featured safer sex skits and information booths. Condoms were distributed free of charge along with information leaflets and educational materials. Workshops were held with drag performers to help them improve their ability to relay prevention messages through art.

Up until August 1998, a total of 106 support group meetings were held nationally, and many more subgroups have met to discuss issues more intimately. A peer-counselling network has now been expanded from Kingston to two other cities, and four additional towns have been identified for outreach activities. A total of 149 support groups of people living with AIDS have reached 737 attendees. Two KABP surveys were conducted in December 1995 and August 1996 and comparisons made. Eighty-five per cent of those surveyed in 1996 now reported knowledge of prevention practices and appropriate perceptions of risk of HIV infection. A 40% increase in the use of condoms and a 30% reduction in self-reported high-risk behaviour was reported. The project is striking in its attempt to provide wide-ranging support for MSM including those living with HIV/AIDS. The holistic nature of the prevention education workshops and the emphasis on counselling and peer support has been well received by MSM. The extension of the work from Kingston to other major towns and cities demonstrates the potential transferability of this style of work. The project has grown out of a self-help community initiative and this adds to its credibility among members of the target group.

MSM CASE STUDY 3

Setting:

Prisons

Country:

Costa Rica

Intervention:

Condom promotion and counselling

Sponsoring institution/organization:

ILPES (an NGO) with the support of the Costa Rican Ministry of Justice

The Instituto Latinoamericano de Prevenci Educacin Salud (ILPES) established a programme with men who have sex with men in Costa Rican prisons. In 1990, a study undertaken among inmates of La Reforma Correctional Centre, the country’s largest penitentiary, revealed a high proportion of HIV infection. No clear policy on prison-based prevention measures had been formulated, despite general recognition of the fact that sexual activity is common among inmates. Previously, there were no HIV awareness programmes directed towards the prison population, and access to HIV antibody tests was limited.

In 1992, ILPES, in collaboration with the Ministry of Justice, began developing a Holistic AIDS Prevention Programme for inmates of Costa Rican correctional facilities. The central objective of this work has been to promote changes in attitude towards HIV/AIDS on the part of inmates, but the approach also addressed the attitudes of correctional personnel. HIV prevention workshops were designed to explore and focus upon the multiple factors that contribute to or inhibit HIV prevention within prisons. To date, these have included work on power; AIDS and safe sex; anger management; sexuality; self-esteem; alcoholism and substance abuse; and holistic health. Workshops use a participatory methodology in which all members take part on equal terms with one another, devising among themselves a system of horizontal communication through such tools as games, exercises, role-play and meditation. Workshops have also been conducted with prison personnel to increase awareness of HIV/AIDS related issues.

Evaluation, conducted during 1995, focused on the outcomes of workshops for prison inmates. By this time, a total of 453 prisoners had participated in the programme and almost all the country’s correctional facilities had taken part. A total of 188 individuals who took part in the programme during the first six months of 1995 were chosen to participate in the evaluation. A questionnaire was distributed to each of them before and after the experience, and changes in responses were systematically recorded. The percentage of inmates who proved knowledgeable about HIV/AIDS increased from 69% before the intervention to 79% post-intervention. In addition, the ability of respondents to communicate effectively with their sexual partners was reportedly enhanced by the workshops. There was a rise in the proportion of respondents who felt able to tell their partner what they liked from 56% to 66%, and a fall in the number of participants who stated that they never communicate with their partner about sexual preferences from 24% to 12%. In terms of condom use and attitudes towards condoms, the proportion of respondents who never used condoms decreased from 51% to 36%, and the number of respondents indicating that they found condoms enjoyable to use rose from 8% to 19%. The holistic workshops had a significant effect on helping inmates feel better about themselves and as a result, a marked improvement in the social atmosphere in the prisons was observed. The uniqueness of conducting a project of this nature within state correctional services, particularly through a process of NGO/governmental collaboration should be noted.

MSM CASE STUDY 4

Setting:

Community

Country:

Bangladesh

Intervention:

Condom promotion and counselling

Sponsoring institution/organization:

The Bandhu Social Welfare Society (an NGO)

The Bandhu Social Welfare Society in Dhaka, Bangladesh, began its community-based work in October 1997. MSM are central to the project management and service provision. A preliminary ethnographic study, together with a risk and needs assessment, was carried out in order to build a clearer profile of male-to-male sex networks. The programme was then designed on the basis of these findings. Primarily, the project has sought to develop and strengthen informal, friendship networks outside of the sexual environment. These are then used to address social concerns such as harassment and police victimization and other personal concerns that the men experience. Outreach activities included an interactive approach to promoting condoms, encouraging discussion and sharing of experiences; the social marketing of condoms; ensuring referral to sensitive and appropriate STD treatment services; and networking with women’s sexual health agencies so as to build appropriate referrals for female partners. By providing opportunities for the men to explore other expressed interests such as dance, fashion design, learning English and vernacular literacy skills, the project aims to enhance its acceptability and encourage longer-term attachment on the part of members of the target group.

Since the project is still relatively new, evaluation to date has largely involved monitoring of service provision and usage. Between October 1997 and January 1998, the Bandhu project received a total number of 960 visits (12 group meetings and 500 individual visits). Over 4 500 condoms were distributed and 1 900 contacts established at public sex environments. Overall, there are clear indications that a socializing/community building/friendship framework is more effective in this context than a more traditional peer education model.

Various aspects of the project’s work have been important to its early success. The fact that the project is beneficiary-led is significant, affording it a high degree of acceptability and ensuring an ethical base for project activities. Similar projects employing this model of intervention have now been established in Lucknow and in New Delhi. This demonstrates the project’s transferability to other regional contexts. The holistic approach adopted, with an emphasis on developing extensive social and support networks, offers a non-clinical style of intervention and acknowledges the wider concerns of the target group. Outreach work, with its focus on friendship building rather than on condom distribution, is an approach that is well received by the target group. HIV/AIDS is still considered to be of relatively low importance, compared with other priority concerns of MSM including family, marriage, employment, income and harassment.

MSM CASE STUDY 5

Setting:

Community

Country:

South Africa

Intervention:

Telephone service

Sponsoring institution/organization:

Triangle Project (an NGO)

A project which has existed in various guises for the past 15 years, and which is now called the Triangle Project, works to meet the education and support needs of gay men in Cape Town, South Africa. The primary assumption of the project is that men are better prepared to protect themselves and partners in the context of HIV if they have a strong gay identity. To this end, the project works not only with gay men, but also attempts to address homophobia within the wider community, as well as to create safer and more accessible health and school environments and provide support and counselling services.

A baseline needs analysis for gay men was carried out initially. Printed information was developed and distributed along with condoms and lubricants in bars and clubs. Outreach education on safer sex and empowerment was carried out in the form of participatory workshops in bars, clubs and other gay venues. Counselling services were provided by telephone and face-to face by a team of trained volunteers. The project trains external groups such as teachers and nurses on issues related to homosexuality. More recently, training has been provided to counterpart agencies elsewhere in Southern Africa (such as GALZ in Zimbabwe). There is a strong focus on training volunteers in order to expand the capacity of the organization to address the needs of gay men. The project is currently completing focus group research examining issues of sexual identity, self-esteem, health-seeking and risk-taking behaviours.

Between June 1997 and June 1998, 236 200 condoms were distributed at urban, township and cruising venues, along with 30 000 sachets of lubricant. Thirty-seven thousand leaflets on safer sex, alcohol and drug use, relationships, ‘coming out’, STDs and hepatitis B have been produced and distributed. A wide variety of people have undergone training on issues such as safer sex and attitudes towards homosexuality. Post-course workshop evaluations indicate increased knowledge and changed attitudes. Participants report valuing the non-didactic and non-prescriptive approach adopted during workshops. The project team is now in the process of developing and applying more systematic evaluation models. The project’s focus on challenging negative attitudes to homosexuality has led to improvements in health service delivery and in education. Through nurturing a strong gay identity, the project has increased the accessibility of HIV prevention, education and support services to gay men in South Africa. However, government funding was cut by 90% in 1997 when prevention of HIV within the heterosexual population was designated a priority.